Wendell L. Belknap
attorney at law
411 Fifth StreetPhone: (503) 657-8946
Oregon City, Oregon 97045Fax: (503) 655-2775
INFORMATION NEEDED TO EVALUATE CASE
(DIVORCE)
INCOMES AND EMPLOYMENT:
HUSBAND:
Occupation:______
Employer’s Name: ______
Employer’s Address:______
Street AddressCityState Zip Code
Employer’s Phone:______
Salary or Hourly:______If Salary, amount: ______
If hourly, rate:______per hourAverage hours per week: ______
If any overtime, describe frequency and circumstances: ______
______
______
Monthly gross income (before taxes taken out):______
Monthly net income (after taxes taken out):______
Describe nature and amount of any other sources of income: ______
______
How long in thisHow long with this
line of work:______employer:______
Condition of health:______
WIFE:
Occupation:______
Employer’s Name: ______
Employer’s Address:______
Street AddressCityState Zip Code
Employer’s Phone:______
Salary or Hourly:______If Salary, amount: ______
If hourly, rate:______per hourAverage hours per week: ______
If any overtime, describe frequency and circumstances: ______
______
______
Monthly gross income (before taxes taken out):______
Monthly net income (after taxes taken out):______
Describe nature and amount of any other sources of income: ______
______
How long in thisHow long with this
line of work:______employer:______
Condition of health:______
HEALTH INSURANCE:
______
Husband\wife insured(Yes or No)Specify whether through husband or wife
______
Children Insured (Yes or No)Specify whether through husband or wife
______
Others covered by this insurance?If yes, specify whom.
Monthly costHow much of cost
of insurance:______for children:______
DAY CARE:______
Being incurred (yes or no)
Provider:
Name:______
Address:______
StreetCityState Zip Code
Phone numbers:______
Annual Cost:______
ASSETS
REAL PROPERTY
PURCHASING HOME:______
Yes or no
If yes:______
Street numberCityState Zip Code
What county:______Names on title: ______
(Husband, wife, or both)
Purchase date:______Purchase price: ______
Fair Market Value:______Balance owing: ______
Monthly payment:______
PURCHASING OTHER:______
PROPERTY:Yes or no
If yes:______
Street numberCityState Zip Code
What county:______Names on title: ______
(Husband, wife, or both)
Purchase date:______Purchase price: ______
Fair Market Value:______Balance owing: ______
Monthly payment:______
Has either party received valuable gifts or an inheritance during the marriage or period of cohabitation? Did either party bring significant assets to the marriage? (Describe)
______
______
______
______
PERSONAL PROPERTY
Vehicles:(Including cars, trucks, boats, trailers, recreational vehicles, motorcycles, etc.)
Year / Make & Model / License #& State / Used by / Value andhow
value obtained / Balance Owed
VALUABLES:(Collections, Jewelry, Antiques, etc.)
Item / Value / How value obtainedDEBTS
Creditor / Amount / Whose (husband, wife, joint)BANK AND INVESTMENT ACCOUNTS
Bank or institution:______Branch: ______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______(For example, checking, savings, money market, CD or mutual fund)
Name on account:______Balance: ______
Bank or institution:______Branch: ______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______
Name on account:______Balance: ______
Bank or institution:______Branch: ______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______
Name on account:______Balance: ______
Bank or institution:______Branch: ______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______
Name on account:______Balance:______
STOCKS AND BONDS
Name of Company / Number of shares / ValuePENSION, PROFIT SHARING, AND STOCK PURCHASE PLANS
HUSBAND:
Name of Fund Administrator:______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______(For example, IRA, SEP, pension, 401k, Keogh, or profit sharing)
Name on account (often referred to as the “Participant”):______
Balance:______Date of Balance: ______
Name of Fund Administrator:______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______(For example, IRA, SEP, pension, 401k, Keogh, or profit sharing)
Name on account (often referred to as the “Participant”):______
Balance:______Date of Balance: ______
Name of Fund Administrator:______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______(For example, IRA, SEP, pension, 401k, Keogh, or profit sharing)
Name on account (often referred to as the “Participant”):______
Balance:______Date of Balance: ______
WIFE:
Name of Fund Administrator:______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______(For example, IRA, SEP, pension, 401k, Keogh, or profit sharing)
Name on account (often referred to as the “Participant”):______
Balance:______Date of Balance: ______
Name of Fund Administrator:______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______(For example, IRA, SEP, pension, 401k, Keogh, or profit sharing)
Name on account (often referred to as the “Participant”):______
Balance:______Date of Balance: ______
Name of Fund Administrator:______
Address:______
Street numberCityState Zip Code
Account number:______
Type of account:______(For example, IRA, SEP, pension, 401k, Keogh, or profit sharing)
Name on account (often referred to as the “Participant”):______
Balance:______Date of Balance: ______
LIFE INSURANCE POLICIES
On Husband’s Life:
Policy Amount: ______Premium Amount:______
Beneficiary Name:______Policy Type:______
Universal, Term, or other
Company Name:______
Address:______
Street NumberCityState Zip Code
Policy Number:______
On Wife’s Life:
Policy Amount: ______Premium Amount:______
Beneficiary Name:______Policy Type:______
Universal, Term, or other Company Name: ______
Address:______
Street NumberCityState Zip Code
Policy Number:______
OTHER ASSETS
______
______
______
______